Transcription:
Minimally Invasive Spinal Surgery

Bill Claproth (Host):  Most people have experienced back pain sometime in their lives. For some, it’s a minor nuisance. For others, it can be debilitating. When physical therapy and medication fails, some are turning to minimally invasive spinal surgery. With us today is Dr. Matthew Quigley. He is the Chief of Neurosciences and Neurosurgery at Guthrie. Dr. Quigley, thanks for being on with us. Guthrie is currently building a new neurosurgery and neurology program which is led by yourself. Maybe you could start off by telling us a little bit about that.

Dr. Matthew Quigley (Guest):  Well, the neurosciences composes neurosurgery and neurology and, really, it has to do with the medical and surgical treatment of diseases that afflict the brain, the spine and the peripheral nerves. So, right now, we’re trying to shore up and expand both the surgical as well as medical capabilities in terms of what type of problems that we can handle here at Guthrie.

Bill:  So, this will certainly help expand your treatment of those type of diseases and help with those different procedures and treatment that you do?

Dr. Quigley:  Right. It will also make things a lot easier for people living in this area because otherwise it would be a 2-hour car drive.

Bill:  Let’s talk a little bit about back pain now and minimally invasive surgery. So, like I said, back pain for some is a nuisance. A lot of people get it. For some, it can completely ruin their quality of life. When is it time to consider minimally invasive surgery?

Dr. Quigley:  Well, the distinction as to when something goes from, say, conservative treatment to surgery is really a function of a couple of things. One is the severity of the difficulty both in terms of the amount of pain--that is, how disabling it is--as well as the distribution of pain. As it turns out, most of the things that we treat and treat successfully are associated, in large part, with pain radiating into either the back or in the cervical spine into the arms. Pain which is restricted entirely to the midline, if it’s degenerative in nature; that is, it’s not associated with a tumor or a fracture or some other thing--is very resistant to any type of surgical treatment and we try very hard not to go down that route when somebody has simply axial pain. The other thing that decides whether somebody needs surgery or not is their neurologic presentation. Most of the people we see in the office have normal neurologic examinations but sometimes they don’t. Sometimes they have weakness, especially at what we term the foot extensors; that is, they have a dropped foot or, in the extreme cases, may have difficulty in terms of control of bladder function. These wind up being essentially neurologic emergencies.

Bill:  So, when you see those, does that signal to you, “Okay. This is a candidate for surgery”?

Dr. Quigley:  Certainly. Anyone who has a serious neurologic problem due to degenerative disease--that is, usually disc disease--they’re going to go to surgery usually pretty rapidly. That is the very small percentage of the type of patients that we see. Most of the patients that we see have had back and leg symptoms usually for a few months of duration and they may have very minor neurologic findings or none at all. So, the first line of treatment is going to be as described in terms of therapy, injections, giving things time. In reality, the majority--that is more than 50% of these things--will take care of themselves on their own. So, we want to give nature enough time to take care of these things if they’re going to take care of themselves. After 3 months or so, it tends to be a persistent problem and that’s when we start thinking about doing surgery.

Bill:  How does minimally invasive surgery differ from traditional surgery? I mean, it sounds like it’s less invasive but can you go a little deeper on that?

Dr. Quigley:  So, the traditional surgery involves making a midline incision which strips the muscles away from the bones. It turns out that this is a very important distinction from what we do with minimally invasive which is to make a skin incision in a transverse way. That is, perpendicular to the long axis of the spine. Then, we use a series of dilators, not to cut the muscle away from the bone but actually just to create a space. The important distinction here is that when you pull that dilator out, all the muscles come back into place. This eliminates what we term “dead space” that’s created with traditional surgery. When you do traditional surgery, you create a space underneath the incision that basically fills up with fluid and that fluid is basically a nice broth for all sorts of organisms and things to grow in; whereas, with the minimally invasive technique, there is virtually no dead space. So, right away, what we can see is a big decline in wound infections. Wound infections complicate anywhere upwards of 3-5% of traditional surgeries. With the minimally invasive technique, it’s less than 1% of the time.

Bill:  So, we don’t want the broth, right? We don’t want the broth?

Dr. Quigley:  We don’t want the broth.

Bill:  Just don’t give me that broth?

Dr. Quigley:  The problem is it’s a nice, warm, nutrient rich, dark place for the bugs to grow.

Bill:  We don’t want that. So, the minimally invasive surgery kind of takes care of that because you’re not creating that pocket of broth, if you will.

Dr. Quigley:  Right. The other thing that we are able to do is to do procedures through a much smaller incision, which, again, is just a lot easier to heal up for the patient. So, a typical two-level or three-level laminectomy that, say, an elderly patient would be offered, which is an L3 through 5 laminectomy, involves an incision on the back, which is easily 6 to 8 inches in length; whereas, our incision for the minimally invasive technique is about an inch and a quarter or so.

Bill:  Now, would this be considered safer, then, than traditional surgery, too?

Dr. Quigley:  Well, it’s safer in the sense that it translates into a much lower infection rate and infections are the most common complication we run into. They can range from being annoying, something that could be treated with oral antibiotics, all the way to the life-threatening if you wind up with a methicillin-resistant staph infection and that staph infection can then become systemic and people can be seriously harmed from these things. So, again, that’s a road you don’t want to go down if you don’t have to. 

Bill:  This isn’t outpatient surgery, right? There is still a hospital stay with this.

Dr. Quigley:  Well, Medicare considers it outpatient because you don’t spend 2 nights. So, you only spend one night. Generally, what we do is plan for the patient to spend 1 night because they have to emerge from the anaesthesia and if it’s not a first case then, generally, it’s 4:00 or 5:00 in the afternoon when they’re waking up and no one wants to take somebody home at that point. We’ve certainly had patients who we’ve operated on first thing in the morning and then by the afternoon they’re like, “Doc, I want to go home!” It’s fine. They can go home. We’re not holding anybody here. But, generally, in order to get over the anesthetic and some of the pain management, initially, right away, it’s just easier to keep folks in overnight in our observation unit.

Bill:  Even though this sounds safer, are there still different risks associated with this?

Dr. Quigley:  Well, all spine surgery carries with it some very distant possibility of very bad things happening: damage to the nerves, damage to the nerves that go to the bladder, all sorts of possible downsides but the likelihood of any of these things happening are tiny fractions of one percent. You know, one in a couple of thousand. Frankly, it’s a function of the experience of your operator and I’ve literally done thousands of these procedures.

Bill:  Then, what is the recovery period like with minimally invasive surgery?

Dr. Quigley:  Well, it’s a little bit easier than for the other types of surgery but not dramatically so. You’re still going to be sore and tired for a week or two following the procedure. I generally limit people not to drive for 10 days to 2 weeks, although people violate those rules all the time. By a month, folks are 90-95% back to normal.

Bill:  So, this sounds like much better than traditional long incision surgery that you talk about. Why would anybody ever get the traditional surgery? Why wouldn’t everybody just get minimally invasive surgery?

Dr. Quigley:  The honest answer is that most surgeons out in the community have not been trained to do it this way. They learned how to do it open and really don’t want to go through the learning process to do it through a series of dilators. It turns out that even though the anatomy is basically the same, it’s very disorientating to a surgeon to look at the same anatomy through a very long, thin tube. It’s easy to get lost. It’s easy not to know your land marks. So, for a lot of surgeons, it’s just a kind of a considerable learning curve that they don’t wish to go through.

Bill:  So, it seems a pretty easy question to answer why someone would choose Guthrie for their back care needs, then?

Dr. Quigley:  Well, I think it’s two fold. One is, certainly, we have the capabilities as far as the minimally invasive approach but the other part of it is that you have surgeons who demonstrate a lot of judgment and sensibility in terms of who needs an operation. So, it’s not a clinic that goes by that somebody doesn’t come into my office and say, “Oh, doctor so and so from elsewhere said I needed an operation,” and I look at them and I say, “Well, we can do some therapy first. We can wait. A lot of these get better on their own. There’s no emergency. If you can bear the pain for a month or so, we’ll see how things go.” That’s the type of approach that we try to take.

Bill:  That sounds like a good approach. Dr. Quigley, thank you so much for your time today. We really appreciate it. And for more information you can visit Guthrie.org. That’s Guthrie.org. I’m Bill Claproth and this is Guthrie Radio. Thanks for listening.